Too Many Babies Miss Out on Medicaid Infant Coverage, Promising Practices Point the Way for States

By: Kay Johnson

For more than 25 years, federal law has guaranteed enrollment for babies born to Medicaid beneficiary mothers, known as deemed newborn coverage, which begins at birth and continues uninterrupted through the first year of life. Passed with bipartisan Congressional support under the Deficit Reduction Act of 1984 (P.L. 98-369), the purpose of this policy is to ensure that babies would not experience even a single day’s break in coverage from the date of birth through the first year of life.

Policy changes in the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. No 101-508) removed some outstanding limitations to strengthen state application of this requirement. As described by the Centers for Medicare and Medicaid Services (CMS) in a letter to states, the changes “effectively… means that all newborns born to women covered by Medicaid for the child’s birth are now covered as mandatory categorically needy.”

States have used various strategies for implementing this special infant enrollment protection to assure these infants keep and maintain coverage. Over the years, however, Medicaid’s increasing operational and technical complexity—resulting in part from lack of administrative oversight and changes in health care delivery such as managed care— have made implementation of continuous infant enrollment more challenging. As a result, states’ approaches to implementation vary widely, and not all are effective.

Our new report found that in each year between FFY 2010-2018, more than 2.3 million infants were counted by states as enrolled in Medicaid and entitled to EPSDT benefits—more than half of the total 3.9 million U.S. births per year. On average, each year more than 500,000 babies in Medicaid were not counted as enrolled for least 90 days continuously.

Most states show a gap between the number of infants counted as eligible and the number continuously enrolled. The percentage varies substantially by state, ranging from a low of 6% to a high of 41% in FFY 2018. Wide variations by state suggest that the gap is the result of state administrative practices in the actual enrollment process or data reporting, not simply variation attributable to the timing of births.

Every state can do a better job implementing this policy. The aim should be to: 1) have every baby with a Medicaid/CHIP financed birth leave the birth facility (e.g., hospital, birthing center) with a card or written document that shows the eligibility/identification number to be used for infant care, 2) require no action by the family during first year to ensure continuous coverage, and 3) use enrollment procedures that are streamlined, clear, and have administrative check points around at both the time of birth and the time of the first birthday.

Based on a scan of state policies and procedures nationwide, the best practices identified in this report emphasize effective administration and communication along the continuum from prenatal period through the first birthday. These include: clear consumer-facing information on state websites, preassigned infant coverage cards given to the mother during prenatal period; mechanisms for families and providers to verify eligibility, training of navigators and out-stationed eligibility workers, and better use of data systems. The report includes examples of Medicaid managed care contract language and sample communication messages for families and providers.

Automatic and continuous enrollment is particularly important given that the Bright Futures Guidelines call for six visits in the first year after an infant leaves the hospital as a newborn (See the AAP Bright Futures recommended schedule which is followed for the EPSDT schedule by most states.)  Immunizations are due at five of those well-baby visits and are urgently needed during the COVID-19 emergency. Developmental screening is due at the 9-month well-baby visit. Maternal depression screening is recommended during well-baby visits and covered by Medicaid in a growing number of states. Moreover, infants are more likely to suffer life threatening conditions than older children. For example, without continuous coverage, a child’s developmental delays may not be detected, a respiratory infection may be left unattended to become life threatening, and services for conditions identified by newborn screening may not be received. Such serious and life-threatening conditions were one factor that stimulated Congressional action and adoption of the automatic newborn and continuous infant eligibility requirements.

Medicaid and CHIP provide coverage for approximately half of all births, and approximately two-thirds of Black, Native American, and Hispanic infants. We cannot achieve equity for babies without effective procedures to ensure continuous coverage and access.

The nation cannot afford to miss the opportunity to provide preventive and other needed health services to 500,000 babies. The first year sets a foundation for future health and well-being; a time when both preventive care and early identification of special health needs are critical. But babies also need moms with access to health care. Having both maternal and infant Medicaid coverage be continuous for one year following a birth is a major step to end disparities in maternal and infant mortality and give our children an equitable start, as Congress and states have opportunities to take action to extend postpartum coverage for one year. This postpartum extension, along with the report’s recommendations to shore up infant enrollment, would go a long way to help more babies and their caregivers access foundational supports that can aid rapid, positive brain development during their first year of life.

Read the executive summary and report. Watch the recording from the “Keeping Infants Covered and Connected to Medicaid” webinar and view the slides.

Kay Johnson has been a leader in health policy for women, children, and families for 35 years. She has been active in Medicaid and children’s health policy at the federal and state levels since 1984 and has served as an advisor to more than 40 state health and/or Medicaid agencies. Her expertise encompasses a wide range of maternal and child health issues. Formerly, she served as the national policy director at March of Dimes, and director of health policy at the Children’s Defense Fund. Prior to her policy career, Ms. Johnson worked with low-income families in early care and education settings.